Utilization Management Medical Director - Remote

About the role

Clinical Advocacy & Support has an unrelenting focus on the customer journey and ensuring we exceed expectations as we deliver clinical coverage and medical claims reviews. Our role is to empower providers and members with the tools and information needed to improve health outcomes, reduce variation in care, deliver seamless experience, and manage health care costs. The Medical Director provides physician support to Enterprise Clinical Services operations, the organization responsible for the initial clinical review of service requests for Enterprise Clinical Services. The Medical Director collaborates with Enterprise Clinical Services leadership and staff to establish, implement, support, and maintain clinical and operational processes related to benefit coverage determinations, quality improvement and cost effectiveness of service for members. The Medical Director's activities primarily focus on the application of clinical knowledge in various utilization management activities with a focus on pre-service benefit and coverage determination or medical necessity (according to the benefit package), and on communication regarding this process with both network and non-network physicians, as well as other Enterprise Clinical Services. The Medical Director collaborates with a multidisciplinary team and is actively involved in the management of medical benefits. The collaboration often involves the member's primary care provider or specialist physician. It is the primary responsibility of the medical director to ensure that the appropriate and most cost-effective quality medical care is provided to members.

Primary Responsibilities

• Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations
• Document clinical review findings, actions, and outcomes in accordance with policies, and regulatory and accreditation requirements
• Engage with requesting providers as needed in peer-to-peer discussions
• Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews
• Participate in daily clinical rounds as requested
• Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy
• Communicate and collaborate with other internal partners
• Participate in occasional holiday and call coverage rotation

Required Qualifications

• M.D or D.O
• Current board certification through the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA)
• Active unrestricted license to practice medicine
• 5+ years of clinical practice experience after completing residency training
• Proven sound understanding of Evidence Based Medicine (EBM)
• Proven solid PC skills, specifically using MS Word, Outlook, and Excel
• Participate in occasional holiday and call coverage rotation

Preferred Qualifications

• Licensure: AZ, MN, NM
• Board certified in Internal Medicine or Family Medicine
• Experience in utilization and clinical coverage review
• Proven data analysis and interpretation aptitude
• Proven innovative problem-solving skills
• Proven presentation skills for both clinical and non-clinical audiences

Pay

The salary for this role will range from $248,500 - $373,000 annually based on full-time employment.

Benefits

In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives.